There should be full information about what resuscitation actually entails.

[OverUnderSidewaysDown]

There have been a lot of press stories about older people being “forced” to sign DNR forms and understandably their families are getting upset.
However I think a lot of people believe that resuscitation is like it is on TV - pads being affixed to the chest, stand back everyone, patient miraculously recovers. It isn’t. It’s a brutal process that can result in smashed ribs, and for frail elderly people it can leave them in a much worse state, either dead or with prolonged suffering.
This should be made public knowledge, no dodging around the facts.
AIBU?

@Trichinella it depends on the circumstances - for example in the community then an ambulance crew will generally have to start a resus unless there are certain conditions that are clearly incompatible with life. And it does mean that attempts have to be made where it is clearly futile and inappropriate.

YANBU. I certainly don't know that much about what it involves.

But often I though DNR might mean you can go to hospital and be helped as much as possible but, if you require resuscitation then they won't do it. But now, it seems like they might be using it almost as a waiver to not take people from care homes or from their own home into hospital at all. It seems almost like it is opting for palliative care but it shouldn't be, should it? Technically shouldn't it mean that you get all the treatment you can prior to needing resuscitation?

I think people may be worried that with all the talk of people not getting taken to hospital or care being rationed, if they have a DNR in place they will just be seen as bottom of the list.

Is there any truth in that or is it just a misguided impression?

I had no idea resus could result in smashed ribs, I'd never have imagined.

How does that happen? Is it the force needed for compressions or something?

I genuinely believed it was like you see on TV, where they shock you a few times and it either works or it doesn't.

What would be reassuring would be to know that healthcare rationing decisions (as opposed to decisions about resuscitation/ventilation) will always be based on current local hospital circumstances only - not decided in advance for whole demographic groups.

I'm advising those I care for to refuse a DNAR at the present time, the decision can be made if they become extremely unwell in hospital later.

That illustrates the problem perfectly - DNRs that would be completely appropriate won't be signed because people are afraid that they're being used for more than just decisions about resuscitation.

If we want people to sign them, we can't use them as a crude measure of how entitled someone will be to healthcare in general over the next few weeks. They have to just apply to resuscitation and that level of care - not to whether or not you qualify for an ambulance to be sent for any other reason, or to have oxygen that might help you.

It's not that rationing can't happen - it's going to have to happen. It's just that encouraging people to sign DNRs to make rationing easier (not because it's necessarily best for them) will lead to fewer DNRs being signed, not more.

You have to compress over the sternum by 5-6cm to be effective. This force breaks ribs in even the youngest, fittest patients let alone an 80 year old with osteoporosis. The sequele from fractured ribs alone can be grim. Pain and subsequent shallow breaths to avoid this can result in pneumonia.

I knew it could crack ribs because someone I know was resuscitated last year after a heart attack and did end up with breakages and brain damage, but much of the brain damage has improved and he is back at work now. He is really glad they did the resusc but then he is only forty something.

In many cases the age and illness that led to a DNR being appropriate might well also mean that someone doesn't get treatment in a time of severe rationing (even lower level treatment, if that has to be rationed).

It should be the condition that determines that, though, not the signed DNR, or people will stop trusting DNRs, and no amount of explaining over and over again how inappropriate resuscitation is will help.

The problem is that people do not understand what dnr means - one family member thought it was like euthanasia! (Ok not the brightest but you can see the problem). Dnr should be widely discussed with families when the person is well, past around 80 it may be appropriate to have a dnr - it does depend on the individual, gut some younger is appropriate. We also need better guidance for families with relatives in icu as to whether treatment should continue, we experienced icu staff trying to try everything for months when it was our wish to stop

@NoMoreDickheads yes, I totally agree that there will be some people where resuscitation is still worthwhile as they are able to recover over time. Unfortunately, there are some people who are very frail or ill with things like severe COPD before getting something like coronoavirus and their chances of being ventilated, resuscitated and recovering again are slim as their bodies/lungs just don't have the strength to recover from the extra pressure they will be put under which is where there should be discussions about DNR wishes in advance.

I read that of the people with Covid19 who get put on to a ventilator only c50% are making it off them again. Even being young and previously healthy beforehand is no guarantee of survival which is pretty horrific.

In my experience of family members going into a care home. On admission, the DNR was discussed and I believe it's almost always put in place by the doctors. The form my MIL had completely very recently did have a place for her signature, but it didn't give her an option to request DNR where a doctor had made the decision. So basically she signed to say it had been discussed with her. On her POA for health, she also had it put in that she did not want to be resuscitated.

With reference to posters who are saying about people with a DNR still being taken to hospital so that they can receive all treatment, I work in a hospital and this would happen often, very elderly patients being brought in from their care homes basically to die in hospital when in reality they should have been made comfortable and allowed to die in their own beds at home. Used to make me very cross that people would think it appropriate to bring a 90 something year old patient with dementia into hospital for treatment at all when it was prolonging the inevitable and distressing for them at the same time.

I remember caring for a lady (in my home carer days) and she told me that she definitely wanted to be resuscitated I'd necessary - I don't think anybody would have done it in the event, but she was about 6 stone and incredibly frail, having chest compressions would have literally crushed her. Awful.

As carers we were told that if we found a patient collapsed or whatever we were to attempt resuscitation until an ambulance came. This happened to a colleague who turned up at a (elderly, requiring home care) client's house and found the client very clearly dead. They were compelled to attempt resuscitation even though they knew the person was dead, which was actually very traumatic for them!!

Yanbu.

There's generally a lack of awareness of how bad lots of medical treatment is. It's a last resort. DD was intubated as a baby and on a ventilator for a week, it was awful, she had to be pumped full of morphine & weaning her off it was grim.

My relative was recovering from cancer treatment. He had a dnr in place but was given cpr Accidentally when he had a heart attack. He had a second one shortly after that killed him where he was not given cpr. I’m actually quite glad it failed because his quality of life was already poor and I think it would have deteriorated further.

@PennyNotSoWise

It's nothing like you see on TV, because the 'chest compressions' they do on actors have to be weak little tiny pushes so as not to hurt them, in reality they need to be fast and forceful. The shocks don't restart a patient's heart, despite what Casualty would like you to believe, they can just help correct an abnormal heart rhythm.

DNACPR is a medical decision. The bit you sign on the form is to say it has been discussed with you, although you can also request that one is put in place (or an advance decision to refuse treatment).

If CPR won't be successful then Dr's can put them in place without discussion with the patient (if they believe the patient wouldn't want to discuss it). If its unlikely to be successful they should discuss it fully and try and get the patients thoughts, they would usually go with the patients wishes but can still put the DNACPR in place if they feel that medically that's the right choice (if it got to that point probably worth giving the option of a second opinion too).

There should also be a discussion of the outcomes of CPR in terms of quality of life and what treatment they / the patient would want (ITU?) and see as acceptable.

Lots of people are really unclear about what they are and how much responsibility they (particularly relatives) have when signing them, they worry they are signing to say it's OK not to try and "save" someone but that's not it at all. Sometimes it's absolutely the right choice to let someone die comfortably in bed, not in pain, with someone holding their hand, not with someone breaking their ribs.

If you make a living will/advance decision and sign it in the presence of a witness then it is legally binding on medical professionals to comply with it. However you can only use one to refuse treatment not demand it.

And it only comes into action if you lose capacity to make/communicate decisions - so you can override it yourself and consent to treatment you'd previously refused. Just like if you had consented to treatment and signed a consent form you could withdraw your consent, you wouldn't be obliged to proceed with the treatment just because your signed the form.

As for why a healthy/young person would want one? Because they cover more than just the question of CPR. You can communicate your wishes about different scenarios (e.g. dementia, terminal illness, brain injury...) And types of intervention you refuse (e.g. CPR, intubation, artificial feeding...). You can also explain your reasoning so that if a scenario comes up that you hadn't covered people will be more informed about what your wishes might have been.

It also includes a line that "for the avoidance of doubt" you still want pain relief etc to keep you comfortable - even if you've refused all life sustaining treatment.

If a doctor disregards an advance decision that had been signed with a witness then they can be prosecuted. Same as if they performed a procedure on you without consent.

Info here is decent and you can create a living will/advance decision: compassionindying.org.uk

@slavetolife your last paragraph is the thing I’ve been going on about.
How distressing to be compelled to perform CPR on someone who is clearly dead and has been for a while.
It’s not fair on anyone concerned, and means there’s something very wrong with the system. It’s not something I would want for myself or any relative of mine.